Thrombolytics in pulmonary embolism

OBJECTIVE: Current guidelines recommend thrombolytic therapy for iliofemoral deep venous thrombosis (DVT). Anticoagulation is the standard treatment for femoral-popliteal and tibial-level DVT. The objective of this study was to evaluate the efficacy of catheter-directed thrombolysis (CDT) using tissue plasminogen activator vs standard anticoagulation alone in patients with lower extremity DVT involving the femoral-popliteal segment. METHODS: A retrospective review was performed of patients referred to the vascular surgery service with lower extremity DVT from 2006 to 2015...

Paradoxical embolism is a known complication with intra-cardiac shunts. It should be considered in the differential as the pathophysiologic mechanism of simultaneous thromboembolism in the venous and systemic vasculature. We present a case of simultaneous deep venous thrombosis, pulmonary embolism and myocardial infarction in the presence of a confirmed patent foramen ovale on echocardiography. Thrombolytic therapy was administered. Subsequent concerns of intracranial hemorrhage on imaging of the brain complicated the management and added to the challenge of co-managing the clot burden in our patient...

BACKGROUND: There is a need for further analyses of subgroups of patients with pulmonary embolism who might benefit from vena cava filters. In the present investigation, we analyze mortality with vena cava filters in the subgroup of stable patients with pulmonary embolism who received thrombolytic therapy. We use a different database than used previously, and we analyze data in more recent years. METHODS: Administrative data were analyzed from the Premier Healthcare Database, 2010-2014, in hospitalized stable patients with pulmonary embolism who received thrombolytic therapy, and may or may not have received a vena cava filter...

We report a case of acute pulmonary embolism with hemodynamic instability diagnosed by a computed tomography pulmonary angiogram. The patient developed pulseless electrical activity during systemic thrombolytic therapy with recombinant tissue plasminogen activator. Successful return of spontaneous circulation was achieved after immediate cardiopulmonary resuscitation with chest compressions for 6 min. His electrocardiogram (ECG) on arrival in the emergency department displayed sinus tachycardia, an S wave in lead I, a Q wave in lead III, incomplete right bundle branch block (RBBB), T-wave inversion (TWI) in leads V1-V3, ST elevation in leads aVR and V1, and ST depression in leads I, II, III, aVF, and V4-V6...

Thrombosis is a major cause of several diseases, i.e. myocardial infarction, cerebral stroke and pulmonary embolism. Thrombolytic therapies are required to induce fast and efficient recanalization of occluded vessels. To evaluate the in vitro efficacy of these thrombolytic strategies, measuring clot dissolution is essential. This study aimed to evaluate and validate high resolution ultrasound as a tool to assess the exact volume of clots in 3D and in real time during in vitro thrombolytic drug testing. This new method was validated by measuring the effects of concentration range of recombinant tissue type plasminogen activator on a blood clot during complete occlusion or 70% stenosis of a vessel...

This report describes a novel approach of accessing the superficial veins of the upper extremity for the treatment of pulmonary emboli (PE) with an ultrasound enhanced thrombolytic infusion catheter. In a patient suffering from saddle PE and impending right heart failure, separate basilic and cephalic venous access sites in the right arm were utilized to insert EKOS EndoWave Infusion Catheter (EKOS Corporation, Bothell, WA) insertion in each pulmonary artery (PA). This technique could be advantageous, particularly for patients at high risk for access site complications and those unable to lie supine for prolonged duration of infusion therapy...

Untreated infective endocarditis (IE) often produces infective emboli in major cerebral arteries. We describe a case of middle cerebral artery occlusion due to IE, which caused severe vasospasm and reocclusion after mechanical thrombectomy (MT). We present the pathologic findings of the occluded middle cerebral artery and investigate the precautions to be taken while performing MT due to IE. A 72-year-old man with atrial fibrillation treated with dabigatran presented with right hemiparesis and aphasia. A diffusion-weighted image showed a high-intensity area in the left temporoparietal junction, and magnetic resonance angiography revealed a left M2 occlusion...

OBJECTIVES: Decision-making around the use of thrombolysis for patients with intermediate-risk (submassive) PE remains challenging. Studies indicate favorable clinical outcomes with systemic thrombolytics (IV tPA), but the risk of major bleeding and hemorrhagic stroke is a deterrent. Catheter-directed thrombolysis (CDT) may be a preferable strategy, as it has been shown to have a lower risk of bleeding than systemic thrombolysis. However, a three-arm randomized control study comparing IV tPA, CDT, and anticoagulation alone, with long-term follow up, would be costly and is unlikely to be performed...

Pulmonary embolism (PE) is a major cause of acute cardiovascular mortality and long-term morbidity. Right ventricular (RV) dysfunction is the key determinant of prognosis in the acute phase of PE, and residual RV dysfunction is associated with the development of post-PE functional impairment, chronic thromboembolic disease, and higher costs of treatment over the long term. Patients with clinically overt RV failure, i.e. hemodynamic collapse at presentation (high-risk PE), necessitate immediate thrombolytic treatment to relieve the obstruction in the pulmonary circulation; surgical or catheter-directed removal of the thrombus can be an alternative option...

BACKGROUND: Thrombolysis in Myocardial Infarction (TIMI) risk index (TRI) was recently evaluated in patients with acute myocardial infarction and found as an important prognostic index. In the current study, we evaluated the prognostic value of TRI in patients with moderate-high and high risk pulmonary embolism (PE) who were treated with thrombolytic agents. METHODS: We retrospectively evaluated the in-hospital and long-term (4-year) prognostic impact of TRI in a total number of 456 patients with moderate-high and high risk PE...

Venous thromboembolism includes both deep vein thrombosis and pulmonary embolism. They pose a significant risk for morbidity and mortality. In an appropriate clinical setting, invasive interventions, including administration of thrombolytics, anticoagulation, and placement of vena cava filter, are warranted. Bleeding, postthrombotic syndrome, recurrence, and filter-associated complications are few of the complications of this disease. More recently, chronic thromboembolic pulmonary hypertension has gained clinical interest in patients with pulmonary embolism and has warranted close follow-up...

Objective: To assess the efficacy and safety of thrombolytic treatment with reteplase in patients with intermediate-risk acute pulmonary embolism. Methods: Ten consecutive patients with intermediate-risk acute pulmonary embolism who received thrombolytic treatment with reteplase at Thrombosis and Vascular Medicine Center, Fuwai Hospital from March to November in 2016 were included.Vital signs, right ventricular diameter, systolic pulmonary artery pressure, and biochemical markers were assessed before and after thrombolytic therapy with reteplase, and bleeding complications were also observed during 3 months follow up...

PURPOSE: Data concerning specific manifestations of pulmonary embolism (PE) among younger patients are scarce. We aimed to evaluate differences in clinical presentation, PE prediction rules, thrombolytic treatment use and PE outcomes in younger (<50 years of age) compared to older patients. MATERIAL/METHODS: We studied 238 consecutive patients with proven PE who were retrospectively categorized into three PE probability subgroups according to the revised Geneva score (RGS) and Wells score (WS)...

The objective was to compare immediate and long-term results of systemic thrombolytic therapy (STT) and catheter-directed fragmentation (CDF) with local thrombolytic therapy (LTT) in patients with massive pulmonary embolism (PE). METHODS: 209 patients with massive PE (the high risk of early death) were included in our study. From 2008 till 2010 in the first group (n=102) STT was performed. From 2011 till 2013 in the second group (n=107) CDF with LTT was carried out. Echocardiography and pulmonary arteriography were performed in all patients on admission to hospital and in 5 days after treatment...

Transjugular intrahepatic portosystemic shunt (TIPS) insertion is commonly performed for refractory ascites or variceal bleeding. However, TIPS dysfunction can be seen in both early and late settings, with shunt thrombosis a particular problem. Treatment of shunt dysfunction commonly involves angioplasty and re-lining, with or without embolectomy, mechanical thrombectomy, or thrombolysis. Ultrasound-assisted thrombolysis has been shown to be successful for treatment of pulmonary embolism, deep vein thrombosis, and peripheral arterial thromboembolism, but has not been described before for TIPS occlusion...

Acute massive pulmonary embolism (PE) is associated with high fatality, and catheter-directed thrombolytic therapy has been shown to be an efficacious treatment for this condition. We herein report a patient who developed acute massive PE but could not undergo the conventional catheter-directed thrombolytic therapy. A Swan-Ganz pulmonary artery catheter was placed at bedside to initiate immediate thrombolytic infusion, which resulted in dramatic clinical improvement. This report underscores a potential role of thrombolytic therapy via a transjugular pulmonary artery catheter in patients with acute massive PE who could not undergo the conventional catheter-based thrombolytic intervention...

PURPOSE OF REVIEW: Acute pulmonary embolism (PE) is a common condition associated with high morbidity and mortality. Prior studies have evaluated the role of systemic fibrinolysis and catheter-directed therapy (CDT) in the management of PE. In this review, we examine current data on risk stratification and the appropriate allocation of systemic fibrinolysis and CDT in acute PE patients with elevated risk of adverse outcomes. RECENT FINDINGS: Classification of pulmonary embolism is based on risk of adverse events, and relies on clinical parameters, imaging findings, and biomarkers...

A short-cut review was carried out to establish whether thrombolysis in addition to therapeutic anticoagulation could be of benefit in submassive (intermediate risk) pulmonary embolism (PE). 64 directly relevant papers were found using the reported search strategy. Of these, three presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. It is concluded that there is insufficient evidence to support the routine use of adjuvant thrombolytic therapy at any dose for patients with submassive PE...

The mechanism of ultrasound thrombolysis (UT) is generally attributed to cavitation. The insufficiency of microbubbles (MB) to serve as cavitation nuclei in the vessel-obstructing thrombi significantly reduces the effectiveness of UT. Taking advantage of the widely performed catheter-directed therapy (CDT), in a thrombo-embolized rabbit IVC model with a simultaneous catheter directed rt-PA thrombolysis procedure, guided moderate mechanical index longer pulses from a modified diagnostic ultrasound transducer, combined with an intraclot infusion of MB, significantly accelerated the thrombolysis process...

OBJECTIVE: Catheter-directed interventions (CDIs) are increasingly performed for acute pulmonary embolism (PE) as they are presumed to provide similar therapeutic benefits to systemic thrombolysis while decreasing the dose of thrombolytic required and the associated risks. This study aimed to identify factors associated with CDI failure and to describe anticipated complications. METHODS: Consecutive patients who underwent CDI for massive or submassive PE between 2009 and 2015 were identified; outcomes and complications were retrospectively collected...